Some amazing new surgery, or a sign of the times?

From an upcoming, much longer post, detailing my second visit to The Washington University in St. Louis. Where I took a course by Shirley Sahrmann and the physical therapy department. You can read about my first visit here.

In discussing structural factors affecting movement, we really honed in on the hip. During our lab portion Shirley recognized one girl -who had a back pain history- walking a bit funky. She told the girl to point her toes in a bit, and see how that felt. The girl walks around the room, “That feels better.”

Shirley, “Of course it does. You have anteverted hips. Who told you to walk with your feet straight?”

Girl, “My last therapist.”

Shirley puts her up on a table prone, lets her legs fall out, and sure enough they went out significantly.

Example of femoral anteversion on right side. (Screenshot from one of Bill Hartman’s videos.)

This girl had been, for god knows how long, forcing her hips into a range of motion she doesn’t structurally have. She’s not going to loosen anything up by keeping her feet straight, she’s only going to jam her hip bones together. Does she look pigeon toed / a little weird with her toes in? Yep. Will that help save her from a hip replacement? Yup.

(I’ll get to how a therapist of all people gave her this suggestion, and a therapist, of all people, continually followed this suggestion. To me, (I believe) the only non-therapist in the crowd, this was…disturbing.)

In the last decade discoveries of structural abnormalities of the hip have sky rocketed. To the point I don’t think we can even say what normal is anymore. What we can deduce from these findings is some people are better suited for certain activities than others.

If you have anteverted hips, it’s going to be extremely hard for you to play most sports without significantly risking blowing out your knee(s), destroying your hips, or wrenching your spine. If you have a shallow hip socket, it’s going to be harder for you to do anything too dynamic as you’re at greater risk of dislocating your hip joint. If you have a large femoral head, it’s going to be hard for you to ever safely squat butt to heels, like an olympic lifter, as you’re going to have to significantly round your lower back to get that low. You can’t get the flexion from your hips -the femoral head is too large, so it hits the acetabulum; you end up having to get the flexion from your spine.

It can suck if you end up with something like the above and yearn to be an NFL athlete, but that’s the way it is. Your body is first concerned with survival, then reproduction; not to be optimally put together to dunk a basketball, throw a baseball, or cut on a dime.

People always reference how athletically gifted professional athletes are. While true, we should also acknowledge how structurally suited they are for their sports. You can’t be an olympic weightlifter if you don’t have hips allowing you to fully squat. Furthermore, many athletes who are genetically advantaged for one sport are genetically disadvantaged for another, sometimes due to basic structural differences. If you’re a swimmer, it pays to have a long torso and short legs, like Michael Phelps. If you’re a sprinter, it pays to have a short torso and long legs, like Usain Bolt. Michael Phelps isn’t much of an athlete once you put him on a track; Usain Bolt isn’t much of an athlete once you put him in a pool. (How much of these variations are acquired through adolescence versus given at birth, I don’t know. Nobody knows. I don’t think anyone even has the slightest clue.)

In the grand scheme of life, these are minor issues. Most aren’t concerned with this level of physical performance or these types of ranges of motion past the age of 18 anyways. It’s no different than 99% of us who realize they aren’t tall enough to make the NBA. Stop the activity, modify the activity, or pick something different and move on.

At least that seemed rationale to me.

Shirley started talking about a 15 year old boy who was having difficulty abducting his hips. He discovered this because he had trouble playing basketball. Think a defensive position and shuffling side to side.

The boy also had trouble flexing his hips past 90 degrees.

So, he goes to the doctor with “mild hip pain and stiffness.” When X-Rays were done they discovered the head of his femurs were larger than “normal.” The doctors surmised these large femoral heads were clunking against his acetabulum, giving him pain. They think they can correct this with surgery.

For this procedure, a “femoral-acetabular osteoplasty,” they:

Cut a ton of tissue to get to the hip joint. It’s not like a knee surgery where there’s not much covering it.

I don’t know a ton about this, but I believe if it’s open surgery they don’t dislocate the hip, but you have to deal with all the issues open surgery come with.

If it’s not open surgery, then the hip is surgically dislocated.

Shave down the femoral neck.

Shave down the femoral head.

Shave down parts of the acetabulum. (This boy had some small fractures.)

Reorient the above structures.

That was the first hip. Post-op the 15 year old was on crutches for ~6 weeks, then he went in and got all the above done again on the other side, after which he was in a wheel chair for a while. 8 months later he was playing basketball again. Shirley closed this story out with, “This is truly some of the marvels of modern surgery.”

I heard all the above, saw the pictures, and was fucking horrified. I don’t consider this a marvel of surgery, a consider this a profound example of a cultural issue. The only reason I can fathom putting your son through a surgery like this is they love basketball / sports, they (or the parents) believe the kid can make it to the NBA, and or they’re worried about their son’s hips as he gets older.

Regarding the last option, if this kid doesn’t flex his hips past 90 degrees and limits how much and often he abducts them, he should be fine. How many people flex their hips past 90 degrees on a regular basis? Most adults I know -other than sitting- don’t flex their hips ever. Why can’t this kid merely make sure to sit in a chair where his hips are below 90 degrees? Same thing with abducting them: Just avoid significant abduction. Is this really crucial for his life between the ages of 18 and 80? No.

How do we know this kid could be at risk for issues down the line? Do we have a sample of 75 year olds who we diagnosed with large femoral heads as 15 year olds, then observed them throughout their lifetimes?

How many people who modify their activities, such as the range of motion they put their hip through, still have issues?

What are the success rates of this surgery? Are those rates on a large sample size? How many other teenagers have had this done? How are these people doing 30 years later?

In hip replacements, a smaller femoral head has actually been been shown to increase the rate of hip dislocation.Is the same true for this surgery? Are you (maybe) decreasing the kid’s hip pain by making the femoral head smaller, yet at the same time increasing the risk he dislocates his hip?

In fact, if a larger femoral head has implications for decreasing hip dislocations, does the kid have a larger femoral head because his body is trying to make sure he doesn’t dislocate his hip while doing activities, like basketball?

Say there is a risk of hip replacements later in life, is it better to take that risk than the guarantee of surgery now? Is a major surgery like this better when you’re a grown, mature adult, than it is when you’re 15? Is it easier to become temporarily handicapped as a 40 year old than it is a 15 year old?

What are the chances he has this surgery and STILL needs a hip replacement down the road?

Does anyone think there is a good, solid answer for any of the questions above? I doubt it. My assumption is this kid is very much a lab experiment due to this surgery’s nascency. What we fully know though is this kid has no chance of competitively playing many sports the way he is now. So, I’m forced to deduce sports are the motivation here. Money and fame? Shit, people will do a lot more than be put in a wheelchair for a while.

I don’t know anything else about this 15 year old, who was probably 16 by the time he played basketball again. I do know, by age 15, if you’re still having issues abducting your hips or playing defense, you’re not making the NBA. If the story on you is anything other than, “He destroys anyone he plays against, ESPN is looking at him, he has a ton of college offers already…” you’re not making the NBA.

I know the probability of a high school basketball player making the NBA is 3 out of 10,000. 3 / 10,000 = 0.0003%.When you’re 15-16, can’t play defense, have had two, MAJOR reconstructive surgeries, and missed an entire year of playing basketball, I’d wager that 0.0003% gets a lot smaller.

A recent study looking at elective surgeries examined four million operations over the course of three years. Of four million, about 28,000 didn’t go as planned. 28,000 / 4,000,000 = 0.007%.

3 / 10,000 = 0.0003% chance of making the NBA.

28,000 / 4,000,000 = 0.007% chance of this surgery not going well. (Considering how much more invasive this elective surgery is compared to others, along with how new it is, this number should probably be demonstrably higher.)

0.007 / 0.0003 = 23.

That is, there is a 23 times greater chance this surgery doesn’t go well than there is this kid making it to the NBA. Not to mention he has to do the surgery twice!

Part of this kid’s issue was a large femoral head and neck. This boy is only 15 and still growing. Who’s to say his femur isn’t going to grow right back? Shirley mentioned the genesis for a large femoral head can be playing sports growing up. The extra pounding causes the femoral heads to hypertrophy. Maybe the reason this kid has large femoral heads is because of the basketball he’s playing. Maybe he’s getting a surgery which will help him go back to an activity that caused his issue to begin with.

Actually, since he’s still growing, how do we know the rest of his hip isn’t going to grow to accommodate his femoral heads? When I was little I remember having a big gap in my front teeth. I was easily a candidate for braces. My dentist thought about things and concluded there was a good chance, once the rest of my teeth grew in, they’d push the front teeth together, thus closing the gap. So, after a while, my body would effectively do the job of braces. If not, then we could entertain braces. My teeth came in, pushed my gap together, and that was that. I have no doubt there are an inordinate amount of dentists who would have done the braces to begin with. Our bodies don’t grow in perfect proportion. Some things come in faster than others. Perhaps this 15 year old’s femoral heads have come in quicker than his acetabulum?

And why does nobody think of the psychological impact of doing this to a teenager? I was on crutches for two weeks in high school and I remember them vividly. You feel awful, lonely, and left out. Going around school on crutches is like wearing a Scarlet Letter. People constantly ask you what happened, want to play with your crutches, and generally act like the assholes that teenagers are. Lord knows how this goes over for a teen in a wheel chair. Because of this, you’re likely to rush your rehab. You simply don’t have the patience an older person has.

Oh, I should probably mention what I mean by chance the surgery “doesn’t go well.” By “doesn’t go well” I mean there is a 23 times greater chance he dies in surgery than makes the NBA. Not risk of infection, or surgical failure, or complications, strictly mortality. (Obviously, the chance of general error is greater than any one error alone.)

Thanks for this very informative report. When I observe the pic of the woman above, it seems her leg/hip is internally rotated to or very close to a normal 45 degrees. Or is it that she’s unable to hold it at zero degrees? I must be missing something here.

How far out the leg goes isn’t the only indicator you want to use. The opinions on this vary, but for me, the discrepancy between internal rotation and external rotation is what’s most important / most useful. Even if the person isn’t truly -verted, you now know how they can move. Whether it’s a -version or some other structural difference isn’t always clear, but whether they have a lot more of one rotation compared to the other is.

Going with the theme of this post, no one seems to know exactly what normal hip range of motion is. So, for me, if the person can get to 45 degrees or more of internal rotation -which is considered either normal or starting to be greater than normal- then I start looking for possible anteversion. Where if, in comparison, they’re quite limited in external rotation, I chalk up anteversion.

I’m not that concerned whether it’s true anteversion or something else going on giving the clinical presentation of anteversion. The clinical presentation is, for me, what I care most about. That is, I now know not to try to externally rotate this person’s hips too much.

That said, I can see how the above picture could be confusing based off what most people are used to looking for with anteversion. I changed the photo to give a more extreme example. Figure that would clear things up as others may have had similar confusion. Thanks for bringing this up.

Thanks Brian I got it. I have had more than a few clients which when I test internal hip/leg rotation as shown by the woman in the pic, their ROM is extreme to where the leg falls to 90 degrees! I’m embarrassed to say I used to think I was required to respond in some less than healthy ways. So then generally speaking, is the safest ground to not force external hip/leg rotation and to alert the client not to do so also?

If you’re seeing a decent amount of people who can reach 90 degrees, I’d double check the lower back. Make sure it’s not rotating, giving you the illusion the person has more hip ROM than they truly have. 90 degrees is severe, and rare in my experience.

Yes, you definitely don’t want to force hip external rotation, and educate the person on this.

I also have a question regarding the picture of the woman above with the imbalance of internal rotation. I myself have excessive internal rotation lying prone like this, (I video taped myself doing this then attempted to measure the degree of rotation off the video.. I got what looked to be between 50 on the right and 55 degrees on the left.)

I wore leg braces as a young child to correct the excessive internal rotation and even my daughter had to wear a corrective shoe on one foot as an infant so this tells me genetics plays a role. I walk comfortably with my toes pointed straight ahead but sometimes will catch myself internally rotating when I am just standing around. I now understand why ballet was a bad idea for me with their objectives being to have beautiful external hip rotation. 🙂

My question is, is it a problem if my excess rotation is symmetrical? Or is it only a problem if asymmetrical like the woman above? I’m now wondering what the best exercises would be for me – with the goal of *never* being at risk for a hip replacement, as well as which exercises I should stay away from.

It’s a “problem” whether it’s one leg or both legs. You just take whatever changes you would make to an anteverted hip, and do it for both legs. You’re not that extreme, but with those numbers you likely have some anteversion going on. (You can see my comments to Joe above on how other things factor in here too.)

While I have my own flavor on this stuff, there are a bunch of good writings on anteversion out there.

As a tangential, somewhat random diatribe: Here’s one tough part about trying to say something of this nature is genetics:

One of the biggest ways children learn is by observing their parents.

Something we’ve found in those with anteverted hips is a propensity to sit in a “W” position, which significantly rotates the hips. I’m sure there are other factors with how the person stands, other sitting positions, etc.

Is it the child has been structurally given certain hips, or is it they have been observing their mom (or whomever), and started to pick up some habits, which have started to structurally change their hips? Where, because the kid has so much growing still to do, you can reverse this through behavior if you catch it early enough?

It’s so hard to know. They’re trying to figure these types of questions with all sorts of things. Personality disorders is a big one. They’re beginning to find research showing if in your lifetime, before you have kids, you develop a phobia; it’s possible to pass that phobia on down to your child WITHOUT that child ever knowing what the thing you’re afraid of is. Your child could be afraid of spiders even if you (mom) never bring up the phenomenon. Meaning it’s not a learned thing, -the kid isn’t afraid of spiders because you taught them to be- the child has the phobia genetically passed on to them. They’re afraid of spiders because it’s in their DNA.

Maybe structural changes get passed on through genetics? Just like a phobia, maybe you can change this if you catch it early enough? Where you go, “Ok, I had femoral anteversion, which presented me with some problems I don’t want my daughter to have. I’m going to make sure my daughter doesn’t do things promoting femoral anteversion as her body is maturing.”

Thanks for the response Brian. I agree that children will consciously and unconsciously mimic all kinds of behaviors from their parents. Good point indeed.

With that being said, I decided to look back at the book my mom kept of me as a baby to double check things and discovered that what I actually had was a “tibial torsion” of the left foot at the age of six months. My daughter had the same thing except instead of wearing a leg brace she wore a “reverse shoe” which just looked like she was wearing two right shoes for a while. She was also approximately 6 months old. So looks like the tibial torsion was passed down, but what I found most interesting is that my problem was not at the hip at all like I thought it was.

You made another good point about the W-sitting – which I could do comfortably all the time as a kid. My girl friends and I would brag that we could sleep that way. It wasn’t until years later in school that I learned that was a bad thing. So in my case maybe that’s where my issues began.

Good post. As a PT I am seeing more and more of these type of surgeries in young people to “fix” their hips, including one where they fracture the pelvic ring to realign the acetabulums. There seems to be no evidence on its effectiveness, not to mention what long term implications there may be for the hips, knees, or spine. No one seems to be bringing this up to the patients before they have the surgeries. But our quick fix culture seems to reinforce this.

Thanks for chiming in. I’d love to hear more about your experience with this. What types of kids are you seeing with this? Is it athletes, random kids with hip issues, kids who are really inactive, kids whose parents are nut jobs, etc?

What are the recoveries like? What type of therapy do you try to do with them?

The kids I have seen are usually late teens early 20s, a matter of fact the doc doing this stuff wont do it on anyone past 40…They are usually athletes with persistent problems. But, they also never get a break for rest or give conservative treatment a chance to work. As you know youth sports tends to be a year round thing. Also orthos are quick to reccomend surgery if therapy “doesnt work”, which usually means doing it for a month without stopping their sport. I dont think non athletic kids in general are getting hip problems to the degree to do something like this. The rehab we are doing when we get these kids is restoring function. I work from an SFMA perspective and movement based analysis is important. By the time they have had these surgeries and down time after they have a lot of things to work on through out their system. So we address this as we try to restore function.

Recoveries are lengthy as you know any major surgery takes time to get over. Results are hard to judge. With insurance restrictions we dont always get the opportunity to follow them for a full year. And once they are out of the surgery distress and walking normally ortho docs dont seem to think they need anymore help. And of course insurance stops paying us when they meet a fairly minimal functional standard of not being in pain and being able to walk. As far as long term consequences, who knows of course.

The frustrating thing is surgeons are doing more of these procedures as we find out more and more that imaging is not predictive of pain and more about how the brain deals with pain, so orthopedic correction may not only not be the best answer, but going down the wrong road entirely.

Hi Brian. I’ve been reading a book you recommended called “Corrective Exercise Solutions to Common Shoulder and Hip Dysfunction”. I think it’s great. I’m taking successful steps in treating low back pain and shoulder pain.

For some time I’ve been dealing with groin pain after falling of my bike. I believe I strained my adductors. Since then I believe I’ve been dealing with adductor tendinopathy. I’m mostly asymptomatic as long as I don’t sprint or do something that stresses the adductors too much. I’ve been doing easy eccentrics for my adductors and I believe it helps a little.

Anyway as I was reading the book you recommended I read a few lines that made me depressed for a few days. 90% of those who have strained their adductors have labral tears???!!! And labral tears are related to a double risk of developing hip arthritis???!!! Wow. Depressing. I’ve been looking at anatomical pictures of the adductors and it’s not like they even attach directly to the acetabulum.

-Having the mindset a labrum tear is detrimental can, and often is, more detrimental than the actual labrum tear.

-Groin pain is not necessarily indicative of an adductor strain.

-For 99% of people (basically, the non-serious athlete), tears and arthritis usually mean nothing. (I have another post on arthritis coming next week you may be interested in. Whenever someone tells me they have something of this nature, I barely pay it any mind. It is so infrequently something to worry about. I spend way more time trying to get people to not be so concerned about this stuff.

Thank you for the reply.
.
– I should have been more precise about my eccentrics. What I do is I put a towel on a slide board, step on it and slowly slide my leg to the side while keeping my torse upright and with good posture. I only do the eccentric work, I don’t go back by working concentrically with my adductors. The reason I do this is that I recall reading about how muscles are often strong concentrically but lack eccentric strenght. I’ve also read that eccentric pull on the tendon makes it undergo remodeling, making it stronger. But most of all, all science aside, I just feel less pain after doing it.

– The quote is about 35% into the book. I was wrong about it being just about adductor strains. It refers to groin pain in general, which is actually kinda more extreme. The quote goes: ” In fact, labral tears have been found in more than 90% of patients presenting with groin pain.” So I don’t know if I am misunderstanding this or if the author himself has misinterpreted something or what. I’d be interested in knowing what you think.

Regarding eccentrics- I’ve read similar things, but I can’t say I’ve ever really dug into this topic. I will say, if it helps you feel better, or you feel it’s beneficial, that has some weight right there. As best I can, I try to let people keep doing things they feel help them.

Misc.- Something I look for with groin strains is gluteal function. A lack of gluteal involvement is typical in hamstring strains, and I believe it can play a role in adductor strains.

“Burnett and colleagues studied 66 patients found to have labral tears by arthroscopy and reported 92% had predominant localized groin pain…”

It appears Evan (author of “Corrective Exercise Solutions”) got that quote a bit twisted. Rather than it being if you have groin pain you probably have a labral tear, it appears to be if you have a (symptomatic) labral tear, you have a very good chance of having groin pain.

A subtle, but important distinction.

The authors of the paper reference other research stating in those with groin pain, 22-55% of patients have been found to have labral tears. I believe this is the statistic you’d be more interested in.

I am a 21 year old male who came across your site and found it very informative and unique compared to other health and wellbeing websites, and so, when I saw this article coincidentally of the specific arthroscopic surgery I underwent just over two weeks ago I felt compelled to share my knowledge. I am no expert of any kind but I will share my experiences:

I grew up playing hockey for as long as I can remember and excelled from a young age. As I got older my focus narrowed and I played hockey for as many as 9 months out of the year, 5 or 6 times a week. Along with possible hereditary dispositions, I was told by doctors that these long term repetitions of certain movements and/or strain caused my hips to form what is called femoral acetabular impingement. This was diagnosed in December of 2012 as I suffered an injury to my left hip that left me struggling to walk. I was made aware of the possible solution of surgery (like above described in your article) to correct my “abnormal” structure. However, I was also able to return to play in the meantime as I was told i wouldn’t be doing any unsalvageable damage in the near future. I continued to play junior hockey for the remainder of the 2012/2013 season and hoped to make it through my last season of junior in 2013/2014. As my symptoms worsened, I made the decision put an end to my year and go ahead with the fairly new procedure, confident that it was the best thing to do for my long term personal health.

Here is why:
The main reason I had this surgery was not for my range of motion issues due to the femoral head impinging on the acetabulum, but instead what is caused by this: degeneration and tearing of the hip labrum. At this point I am still deciding if I will play competitive hockey again, but I was certain I want to maintain a healthy and active lifestyle as long as I possibly can. Ignoring my painful symptoms, I was told, would very likely lead to the early onset of arthritis resulting in the need of a hip replacement at young age. They may not have done this exact procedure for 50 years and know the exact pros and cons for it, but it seemed apparent this would be something in my best interest to undergo. However, if I was not experiencing pain or my impingement was not severe, surgery would not be recommended as I will not be getting my right hip done unless symptoms become present and severe. In hockey players, this condition and surgery is becoming more and more frequent due to constant twisting and pivoting during skating as well as twisting and torquing while shooting as well as in goalies who go up and down in the butterfly position. Due to this, I had one acquaintance who I knew had this exact procedure done and also strongly recommended going through with it. And so I did.

I am not certain in years to come just what condition my hips, or entire body for that matter, will be in and I may after all require a hip replacement or endure further problems. Despite this, I am confident I did the most I possibly could in hopes to retain my active lifestyle for many years to come.

My surgery was very successful (I did in fact have a severely torn labrum revealed by the over 4 hour arthroscopic operation) and I am very thankful for my orthopaedic surgeon who I couldn’t say enough good things about. His confidence and experience in this condition was a major deciding factor for me to go ahead with this procedure and hopefully have me back feeling better than ever as well as return to all my normal activities. I am not yet in a position to confirm that this surgery has followed through with all that was claimed to me, so I would not yet recommend it, but even if it doesn’t I know I did all that was in my power, not for the sake of playing professional hockey or making millions of dollars, but for the best odds of personal optimal health.

Just wanted to clarify, what procedure exactly are you referring to? A surgery to repair a labrum, or the more involved one, consisting of shaving the femoral head and changing the structure of the hip complex, I mentioned above?

I know you’re only 2 weeks post-op, but what, if any, has your physical therapy been like so far?

It was the more involved and quite extensive surgery. There was debridement of the acetabular as well as shaving of the neck of the head of the femur to give it the desired shape to move freely and not impinge during certain movements. To do so there were also 3 “tent peg” like anchors put into my acetabulum to secure the labrum in the fixed position. The tear in the labrum was a result of the condition from the mis-shaped joint.

I am currently on crutches with no physical therapy with about 50 pounds weight bearing (I am about 165-170 lbs) and am instructed to continue to do so until 6 weeks post op. However, I am feeling very well and have to restrain myself from walking on it and ditching the crutches behind.

People seem to go back and forth in how they represent percentage. Especially with sports. “Their winning percentage is .500.” Technically, it would be “Their winning percentage is 50%,” but that’s rarely said colloquially. Though I know the technical way is to x by 100, I often leave it as I did above, 3 / 10,000 = 0.0003. I think it’s also more dramatic that way in writing, seeing all those zeros.

Very true! I forgot to mention when it’s .500 in sports it’s often said as “their record is five hundred.”

It’s not like I would use the same notation on a statistics test (especially having a mathematics minor). But I go back and forth as to what resonates for people, understanding most don’t have that background.

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